Booking visit

Question 1

When is this ideally done?

Answer 1

At or before 10 weeks gestation

Question 2

Confirmation of pregnancy

Answer 2

+ve urine pregnancy test + symptoms of pregnancy = confirmation

Dating scan to be offered to all women between 10-14 weeks

Question 3

At what ages are women more at risk of obstetric complications?

Answer 3

<17 and >35

Question 4

PMH - women needing additional care

Answer 4

HTN
DM (GDM more common if first degree relative = diabetic)
BMI>30
Age>40 and teenagers 
Psychiatric disorders
Smoker
Epilepsy
Recreational drug use
Thromboembolitic disease

Question 5

Obstetric HX - women needing additional care

Answer 5

Recurrent miscarriage (x3)
Grand multip (>6 children)
Previous preterm birth
Still birth/neonatal death
Pre-eclampsia
C-section
Pueperal psychosis 
Baby with congenital abnormalities 
Baby <2.5kg or >4.5kg

Question 6

Gynae Hx

Answer 6

Sub-fertility - increases peri-natal risk
Assisted pregnancy - higher chance of multiple pregnancy
Uterine surgery - probably deliver c-section
Cervical smear - rearrange for 12 weeks postpartum if due during pregnnacy

Question 7

Social Hx

Answer 7

Smoking/alcohol
Married/single/support at home
Employment - break for history
Housing, finance, domestic abuse - everything OK at home?

Question 8

Examination

Answer 8

General health + nutritional status
BMI calculated (>30 = higher risk)
Baseline BP

Abdominal examination - uterus palpable at 12 weeks

Question 9

Routine blood tests

Answer 9

FBC and screen (anaemia, thombocytopenia, sickle cell, thalassemias)

Blood group and Rh status (Rh -ve - anti-D given at 28 weeks and within 72 hours of delivery)

HIV - need to use antiretrovirals throughout pregnancy and up to 6 weeks for the newborn + CS + increased risk of pre-clampsia, IUGR and stillbirth

Hepatitis B - notifiable disease, 90% of infected neonates become chronic carriers, neonatal immunisation

Syphilis - usually results in miscarriage, stillbrith or serious congenital malformations
Prompt treatment with benylpenecillin + GUM referral
Mother must recieve treatment > 4 weeks before delivery, otherwise newborn requires IV

Question 10

Non-routine screening tests

Answer 10

Chlamydia and Gonorrhoea (women <25 encouraged)
TC - neontal conjunctivitis (30%), neonatal pneumonia (15%)
NG - postparetum endometritis, chorioamnionitis, neontal opthalmia (40%)

Hep C - Hx of drug abuse/obstetric cholestasis

Group B strep

BV

Question 11

Non-routine urinalysis

Answer 11

Urine microscopy - MSU to check for asymptomatic bacteruria (can lead to pyelonephritis in 20%)

Urinalysis - glucose, protein, nitrites - DM, renal disease, UTI

Question 12

Health promotion and advice - drugs

Answer 12

Folic acid - 400mcg/day until 12 weeks

Vit D - 10ug/day (BMI>30, south asian or afro-caribbean)

Iron supplements if:
Hb <110 in first trimester, <105 2nd trimester, <100 3rd trimester

DO NOT TAKE VIT A

Anti-epileptics - carbamzapine and Lamotrigine are safest during pregnancy

Question 13

When should 5mg folic acid be prescribed?

Answer 13

Hx of neural tube defects (woman and partner), DM or on an antiepileptic

Question 14

Health promotion - lifestyle

Answer 14

Diet - well balanced ~2500 calories a day

Avoid alcohol and smoking (nicotine replacement)

Infection avoidance - drink pasturised milk to avoid listeriosis
Avoid soft or blue cheese, pate and uncooked/partially uncooked food

Question 15

Antenatal planning - pre-eclampsia

Answer 15

More common in nulliparous women and 15x more common in women with previous Hx
Low dose aspirin given to those at risk (75mg)

Question 16

Previous C-section

Answer 16

Those who had C-section for non-recurrent reasons (breech, foetal distress etc.) may be offered a trial of vaginal delivery

NICE guidelines do not recommend vaginal delivery after 3 previous CS

Question 17

Smokers

Answer 17

Increased risk of SGA - foetal hypoxia and ischemia due to higher levels of CO and nicotine

All smoking mothers offered CO blood level reading

Pregnancies at risk of IUGR, SGA, placental abruption, preterm labour, stillbirth and SIDS

Question 18

Anemia

Answer 18

Increased blood volume (40%) –> reduction in Hb
Offered iron supplemantaiton if:
Hb <110 in 1st, <105 in 2nd, <100 in 3rd
or if MCV <80

Question 19

Gestational DM

Answer 19

All women offered glucose tolerance test at 26 weeks
or
16 weeks if:
BMI>30
Previous GDM
1st degree relative with DM
South Asian or Afro-carribbean
Previous baby's weight >4.5kg